Oral Surgery Consent


INFORMED CONSENT FOR ORAL SURGERY

Some potential complications and risks are associated with the extraction of teeth despite the highest degree of skill. These risks and complications should be understood and accepted by each patient prior to consenting to the operation. Please read the following paragraphs and initial each that may apply to your case as explained to you by Dr. Taylor Clark, Dr. Jayson Clark, or Dr. Jon Pluid.

Damage to fillings or restorations in teeth adjacent to teeth being removed can occur. The patient assumes responsibility for replacement of these fillings.

Damage to the nerve fibers that supply feeling to the lower lip, teeth and gums and damage to nerve fibers that supply feeling and some taste to the tongue can occur. This may occur if the teeth lie very close to these nerves. It is not always possible to determine the exact position of the teeth in relationship to the nerves. Decreased or numb feelings in the lower lip, teeth, gums and tongue is usually transient and complete feeling usually returns in six months. However, on rare occasions, the loss of feeling may be permanent.

Opening into the maxillary sinus can occur upon removal of some teeth in the upper jaw. This complication usually heals rapidly without complication, although on rare occasions, further surgery is needed to close the opening.

I understand that if I am given a prescription for pain medication which contains a narcotic, I must not drive a motor vehicle or operate dangerous machinery while taking these medications.

The nature and purpose of the proposed surgical procedures as well as the specific complications I have initialed above have been explained to me. The alternatives to having this surgery performed, including no treatment at all, have been explained. I understand fully the risks and benefits and consent to the procedure.



  • Tooth #
  • Signature
  • Pt Name
  • Witness


  • Date





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